A Data-Driven Approach to Team Training for Nurses in a Level II Trauma Center.

This prospective investigation describes the process of designing a targeted, data-driven team training aimed at reducing identified process inefficiencies or flow disruptions (FDs) that threaten the optimal delivery of trauma care. Trained researchers observed and classified FDs during 34 trauma cases in a Level II trauma center. Multidisciplinary trauma personnel generated interventions to identified issues using the human factors intervention matrix (HFIX). This article focuses on one intervention: a formal trauma nurse training program centered around leadership, teamwork, and communication. The training was well perceived and was found to have a significant impact on participant knowledge of course content; t (65) = -13.92, p ≤ .01. By using hospital-specific data to drive intervention development from multidisciplinary team members, it is possible to develop effective solutions aimed at addressing individual threats.

Training monitoring skills in helicopter pilots.

BACKGROUND: Prior research has indicated that ineffective pilot monitoring has been associated with aircraft accidents. Despite this finding, empirical research concerning pilot monitoring skill training programs is nearly nonexistent. E-learning may prove to be an effective method to foster nontechnical flight skills, including monitoring. This study examined the effect of using e-learning to enhance helicopter aircrew monitoring skill performance. METHODS: The design was a posttest only field study. Forty-four helicopter pilots completed either an e-learning training module or a control activity and then flew two scenarios in a high-fidelity flight simulator. Learner reactions and knowledge gained were assessed immediately following the e-learning module. Two observer raters assessed behaviors and performance outcomes using recordings of the simulation flights. RESULTS: Subjects who completed the e-learning training module scored almost twice as high as did the control group on the administered knowledge test (experimental group, mean = 92.8%; control group, mean = 47.7%) and demonstrated up to 150% more monitoring behaviors during the simulated flights than the control subjects. In addition, the participating pilots rated the course highly. DISCUSSION: The results supported the hypothesis that a relatively inexpensive and brief training course implemented through e-learning can foster monitoring skill development among helicopter pilots.

Application of broken windows theory to identify flow disruptions in neurosurgery procedure.

Addressing flow disruptions (FDs) in neurosurgery requires a multifaceted approach. Strategies like improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. Thirty neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis). Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption every 2.7 min. Instead of focusing exclusively on errors and adverse events, we propose conceptualizing the accumulation of disruptions as "threat windows" to analyze potential threats to the integrity of the care system. This perspective allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

The Effects of Flow Disruptions on RN Circulators.

The RN circulator role includes maintaining situational awareness and mitigating risks to patient safety in the OR. Flow disruptions-deviations that threaten the safe and efficient flow of surgery-may contribute to the occurrence of errors and negatively affect safety for patients and health care providers. We used an existing data set to explore the effects of flow disruptions on the RN circulator. To create the data set, doctoral-level human factors students observed 24 cardiac surgery procedures and recorded the types and durations of disruptions. We used a human factors taxonomy to classify the flow disruptions. Of the 1,470 events observed, interruptions were most prevalent (66.67%), followed by coordination issues (15.37%) and communication breakdowns (8.37%). Layout (7.21%), equipment (1.77%), and usability (0.61%) issues accounted for the remainder of the disruptions. Perioperative leaders should work with staff members to minimize workflow disruptions and provide support for identifying and documenting flow disruptions.

A Theoretical Model of Flow Disruptions for the Anesthesia Team During Cardiovascular Surgery.

OBJECTIVES: This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions. METHODS: Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events. Observations were classified using a human factors taxonomy. RESULTS: Of 301 disruptions observed, interruptions (e.g., those events related to alerts, distractions, searching activity, spilling/dropping, teaching moment, and task deviations) accounted for the greatest frequency of events (39.20%). The average amount of time needed for each disruption to be resolved was 48 seconds. Across 49.87 hours of observation, more than 4 hours were spent resolving disruptions to the anesthesia team's work flow. CONCLUSIONS: By defining a calculable error space associated with these disruptions, this research provides a conceptual metric that can serve in the identification and design of targeted interventions. This method serves as a proactive approach for recognizing systemic threats, affording healthcare workers the opportunity to mitigate the development and incidence of preventable errors precedently.

Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care.

OBJECTIVES: Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events. METHODS: Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). RESULTS: Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging. CONCLUSIONS: Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

Proactive Safety Management in Trauma Care: Applying the Human Factors Analysis and Classification System.

INTRODUCTION: This article examines the reliability of the Human Factors Analysis and Classification System (HFACS) for classifying observational human factors data collected prospectively in a trauma resuscitation center. METHODS: Three trained human factors analysts individually categorized 1,137 workflow disruptions identified in a previously collected data set involving 65 observed trauma care cases using the HFACS framework. RESULTS: Results revealed that the framework was substantially reliable overall (κ = 0.680); agreement increased when only the preconditions for unsafe acts were investigated (κ = 0.757). Findings of the analysis also revealed that the preconditions for unsafe acts category was most highly populated (91.95%), consisting mainly of failures involving communication, coordination, and planning. CONCLUSION: This study helps validate the use of HFACS as a tool for classifying observational data in a variety of medical domains. By identifying preconditions for unsafe acts, health care professionals may be able to construct a more robust safety management system that may provide a better understanding of the types of threats that can impact patient safety.

Coding Human Factors Observations in Surgery.

The reliability of the Human Factors Analysis and Classification System (HFACS) for classifying retrospective observational human factors data in the cardiovascular operating room is examined. Three trained analysts independently used HFACS to categorize observational human factors data collected at a teaching and nonteaching hospital system. Results revealed that the framework was substantially reliable overall (Study I: k = 0.635; Study II: k = 0.642). Reliability increased when only preconditions for unsafe acts were investigated (Study I: k =0.660; Study II: k = 0.726). Preconditions for unsafe acts were the most commonly identified issues, with HFACS categories being similarly populated across both hospitals. HFACS is a reliable tool for systematically categorizing observational data of human factors issues in the operating room. Findings have implications for the development of a HFACS tool for proactively collecting observational human factors data, eliminating the necessity for classification post hoc.

Clockwise and counterclockwise rotating shifts: effects on vigilance and performance.

INTRODUCTION: Arguments against counterclockwise shift schedules, such as those used in air traffic control, are prevalent in the literature; however, few studies have examined direction of rotation in rapidly rotating schedules. The present study directly compared clockwise (CW) and counterclockwise (CCW) rapidly rotating shiftwork schedules on measures of complex and vigilance task performance. METHODS: Participants (n = 28) worked day shifts for the first week of the study (0800-1600 h), followed by 2 wk of either a CW (n = 14) or CCW (n = 14) shiftwork schedule. Participants completed three 1.5-h sessions on the Multiple Task Performance Battery (MTPB) on each shift. Each session contained active- and passive-task components. In addition, participants completed a 0.5-h Bakan Vigilance Test at the beginning and end of each shift. RESULTS: A three-way, rotation condition by shift by session interaction (F (8,19) = 3.0, p < 0.05) for the active task composite scores and a rotation condition by shift interaction (F (4,23) = 6.2, p < 0.05) for the Bakan Vigilance Task indicated that effects of rotation condition were modulated by shift type, such that on particular shifts, performance in the CCW rotation was actually better than in the CW rotation. DISCUSSION: These data do not support the hypothesis that a CW rotation will result in better outcomes on complex or vigilance task performance. The results of this study indicate that two problem areas in both CW and CCW rapidly rotating shift schedules are early morning and midnight shifts.

Clockwise and counterclockwise rotating shifts: effects on sleep duration, timing, and quality.

INTRODUCTION: Many air traffic control specialists (ATCS) work relatively unique counterclockwise, rapidly rotating shift schedules. Researchers recommend, however, that if rotating schedules are to be used, they should rotate in a clockwise (CW), rather than a counterclockwise (CCW) direction. Unfortunately, few studies have examined CW and CCW rapidly rotating shifts. This study was designed to partially remedy this lack by examining the effects of both types of schedules on sleep duration, timing, and quality. METHODS: Participants (n = 28) worked a week of day shifts (0800-1600 h) followed by two weeks of either a CW (n = 14) or CCW (n = 14) shiftwork schedule, including early morning (0600-1400 h), afternoon (1400-2200 h), and midnight shifts (2200-0600 h). Participants recorded sleep data and subjective ratings of sleep quality, sleepiness, and mood in daily logbooks and wore wrist activity sensors to provide an objective source of sleep/wake data. RESULTS: There was no effect of rotation condition for any of the sleep measures. A main effect for Sleep Period (F (5,16) = 40.9, p < 0.05) indicated that both groups received less sleep prior to the early morning shifts than before the afternoon and midnight shifts. Sleepiness ratings were highest at the end of the midnight shift. DISCUSSION: Rotation condition did not play a significant role in the results of any of the sleep or subjective measures. The results of this study indicate that two problem areas in both CW and CCW rapidly rotating shift schedules are early morning and midnight shifts.

Clockwise and counterclockwise rotating shifts: effects on temperature and neuroendocrine measures.

INTRODUCTION: Most researchers suggest that shift rotation in a clockwise (CW) direction produces less disruption of circadian rhythms than rotations in a counterclockwise (CCW) direction. This is based on extrapolation from quasi-experimental studies of shift workers and research on the effects of jet lag that indicate that westward travel results in less disruption of circadian rhythms. METHODS: The effect of direction of rotation on cortisol, melatonin, and rectal temperature was examined in participants randomly assigned to either a CW (n = 14) or CCW (n = 14) shift rotation. RESULTS: Results revealed lower amplitude [F(1,21) = 14.6, p < 0.05] and a delay of the acrophase [F(1,21) = 4.4, p < 0.05] in temperature for the CCW group. Sample time effects for cortisol and melatonin revealed normal circadian variation for both rotations, although melatonin levels on the midnight shift were clearly suppressed relative to baseline melatonin levels. DISCUSSION: The changes observed in the temperature rhythm for the CCW rotation may be related to adaptation or shift-work hardiness; however, it is unclear if these differences indicate beneficial or detrimental changes for the individual. The fact that there were no significant effects of rotation condition for cortisol or melatonin argues against a detrimental effect. These findings are bolstered by performance and sleep data, reported elsewhere from this study, indicating a lack of significant differences as a function of rotation condition.

Human error and commercial aviation accidents: an analysis using the human factors analysis and classification system.

OBJECTIVE: The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with two types of commercial aviation (air carrier and commuter/ on-demand) accidents using the Human Factors Analysis and Classification System (HFACS). BACKGROUND: HFACS is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify human factors trends associated with military and general aviation accidents. METHOD: Using data obtained from both the National Transportation Safety Board and the Federal Aviation Administration, 6 pilot-raters classified aircrew, supervisory, organizational, and environmental causal factors associated with 1020 commercial aviation accidents that occurred over a 13-year period. RESULTS: The majority of accident causal factors were attributed to aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS causal categories and traditional situational variables such as visual conditions, injury severity, and regional differences. CONCLUSION: These data will provide support for the continuation, modification, and/or development of interventions aimed at commercial aviation safety. APPLICATION: HFACS provides a tool for assessing human factors associated with accidents and incidents.